The Hospitalist Is In . . .
Tuesday, September 11, 2007
When Joan Irvine's husband collapsed in July from heart problems, he was rushed to Montgomery General Hospital. There, he was admitted not by the family's primary care doctor but by a hospitalist, one of a growing breed of physicians specializing in inpatient care.
"It went pretty well," said Irvine, a nurse, of their hospital experience. "The hardest thing is you're dealing with a person who doesn't know you, doesn't know your history, and you're starting from scratch."
You may never have heard of hospitalists. But land in the hospital and you're increasingly likely to find yourself dependent on one, representing a fundamental shift in how people receive inpatient care.
In the past 10 years, despite resistance from primary care physicians and fears that the development could erode continuity of care, the ranks of hospitalists have exploded from a few hundred physicians in 1997 to 20,000 today -- about as many as there are gastroenterologists or neurologists. That's the fastest growth for any medical specialty in the country, according to the nonprofit Society of Hospital Medicine (SHM), the professional society for hospitalists.
Initially, the trend was driven by hospitals and managed-care groups, seeking to cut costs and improve care quality. But with hospital reimbursement rates failing to keep up with their costs, many primary care physicians are being won over and now find the hospitalist arrangement saves them time and money. And although many patients may resent not having their doctor at their bedside, just when they need him or her the most, the hospitalist movement, by most accounts, is here to stay.
"The majority of hospitals in the United States have hospitalists, because it's a better utilization of resources, of time, of communication skills and quality of care," said Ahmed Nawaz, who leads a hospitalist practice based at Holy Cross Hospital in Silver Spring.
Yet many patients are unaware of the trend. "We don't introduce ourselves as 'hospitalists,' " said Washington internist Michael Molineux, director of the hospitalist program at Georgetown University Hospital. "Most patients don't know what it is or what it means."
Molineux said he stopped using the word when many patients understood him to say "hospice" and thought they were at death's door. "I say I'm an attending physician in internal medicine and I'll be in charge of the team taking care of them," he said. That means assuming responsibility for everything from admission to discharge, including making patient rounds and ordering all needed tests and procedures.
Although hospitalists say they offer a consistent, reassuring presence for patients, Steve Lewis's experience may be typical. Lewis, of Silver Spring, went to the emergency room at Holy Cross with a headache and fatigue and was diagnosed with leukemia. He was admitted by Nawaz's team and spent six weeks receiving treatment before recently being discharged. An upbeat man, Lewis said he was generally pleased with his care, which he believed was managed by his oncologist. It wasn't, but Nawaz, who called in the oncologist and other consultants, shrugged off the mix-up. "We don't take the thunder away from the oncologist," Nawaz said. "We know he's the main guy in this patient's care."
Still, Lewis found some aspects of his care confusing. "To me it was a barrage of different doctors," he said. "Sometimes I didn't know who to ask, if I had a question."
Most hospitalists are internists; 11 percent are pediatricians. By 2010, SHM projects 30,000 hospitalists will be practicing. Medical students may soon choose which side of the hospital divide they want to work on: inpatient or outpatient. For now, it's your physician's choice whether to refer you to a hospitalist or to follow your inpatient care. If you have no primary care physician, a hospitalist will probably manage your hospital stay.
Although patients are often confused about the role of hospitalists, hospitals embrace the new model, nationally subsidizing $50,000 to $60,000 of the average hospitalist's $169,000 salary. Managed-care organizations, such as Kaiser, have established their own hospitalist practices. There is financial incentive to do so: Studies show hospitalists manage care more efficiently and reduce hospital stays. Hospitalists say they think that's because they order tests and procedures more promptly.
Shortening hospital stays is to the patient's advantage as well, said Frederick Finelli, chairman of the D.C. Board of Medicine.
"You want to get the patient out of the hospital. Look at the incidence of hospital-acquired infections," he said.
Hospitals and managed-care organizations are betting that the use of hospitalists will result in better care. "We've seen improvements associated with reduced length of stay in the hospital and better-quality outcomes," said Silver Spring pediatrician Blair Eig, senior vice president for medical affairs at Holy Cross. Whether hospitalists will also reduce medical error rates is not yet known.
In the largest hospitalist study to date, presented at the 2007 Hospital Medicine annual meeting, Peter K. Lindenauer, associate professor of medicine at Tufts University School of Medicine, found that hospital stays are a half-day shorter if managed by a hospitalist, with mortality and readmission risks comparable to those of family physicians or general internists. Smaller studies found improved patient satisfaction and quality of care.
"I'd like to see them measured the same way as everyone else: how satisfied are their patients, what is the level of service they provide," said SHM President Rusty Holman, a hospitalist in Nashville. "It's important for everyone to be held to the same standards."
Hospitalists' biggest selling point is that they're always on-site.
"On the quality-of-care side, there are some important inherent advantages, in that these are physicians specially trained to manage patients," said Susan Frampton, president of Planetree, a nonprofit organization devoted to improving patient-centered care in hospitals. "It's very challenging these days for physicians in private practice to do that. They squeeze in short visits to the hospital and run back to manage their practice."
But other patient advocates, including retired internist Barbara Blaylock of Bethesda, worry that although hospitalists are expert at managing hospital stays, they also may contribute to the fragmentation of care. "Hospitalists rotate every few days and go off duty, often at 5 p.m., so patients and families may be confused about who the doctor in charge is at any given point in time," she said.
Frampton also hears hospital patients in focus groups complain about not having the familiar face of their doctor. Planetree encourages hospitals to train hospitalists in strong communication skills and in working with families.
"They've got to be able to inspire a comfort and confidence level very rapidly," Frampton said.
For patients who have no regular doctor, hospitalists should be an improvement. "These are patients who otherwise were not getting seen, or seen only by interns and residents," said Finelli, who is also president of the medical staff at Washington Hospital Center.
A major challenge in the new model of care is communication between hospitalists and private physicians. Without immediate feedback from the latter about a patient's medical history, hospitalists may well repeat diagnostic tests or not know what has already been tried. Hospitalists say they do their best to reach patients' doctors. But they admit communication remains a challenge.
"Is there room for improvement? Absolutely," Nawaz said.
Many primary care physicians accept the role of hospitalists. In a recent survey by the American Medical Association, nearly three-quarters of primary care physicians said hospitalists provide them "a valuable service." Yet those same doctors seemed less enamored with the quality of care delivered by hospitalists. In the survey, 95 percent of hospitalists who responded said they believed their specialty had improved the overall quality of hospital care, but only 40 percent of primary care doctors thought so.
For many private doctors, hospitalists make economic sense. "It's become more and more difficult to get outside practicing physicians to come and work in the hospital," said Bob Karp, president of the Montgomery County Medical Society. "The reason is, they find it's not financially acceptable." Doctors can make more money seeing patients in their office instead of driving through traffic to visit one or two in the hospital.
Olney internist John Lodmell said he was very skeptical at first about the value of hospitalists. "But hospitalists are in the hospital all the time," he said. "ER docs like them because they respond right away. The nurses like them because they're up-to-date and they communicate well. And our families are reasonably satisfied with the care they get."
But Gary Raffel, a Bethesda osteopath, is adamant that he would not refer his patients to a hospitalist. "I prefer to care for my own patients in the hospital -- a setting that can be quite frightening and full of uncertainty to them," he said. "As a significant segment of my practice includes those in their 80s, I feel that they deserve to see me in that setting and not a stranger."
That's a position that some patients cheer.
"My dad has well-controlled and long-standing diabetes," said Beth Barnett of Chevy Chase. "His doc has been juggling the various medications and knows his eating habits and things like tolerance for pain, what hasn't worked in the past, how to hold edema at bay. The thought of some new doc starting with a clean slate and a medical history taken from the sick bed gives me the willies."
Larry White of Olney, a full-time caregiver for his mother, said he was upset when hospitalists at Montgomery General, where she was recently hospitalized, missed some nuances in her medication regimen because they weren't as familiar with her medical history.
Working with the team, White straightened things out. But had he not been there, he is not confident things would have gone well, despite the staff's best efforts. Still, White isn't pushing to turn back the clock and return to pre-hospitalist days. He'd prefer that patients have the best of both worlds -- the primary care doctor's knowledge of patient history plus the hospitalist's availability.
"If you have a problem in the middle of office hours," he concedes, "you won't have the access to the primary care physicians which you do with the hospitalist."
Beth Baker is a Washington area freelance writer and the author of "Old Age in a New Age -- The Promise of Transformative Nursing Homes." Comments:firstname.lastname@example.org.